Publications (56) View all
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Article: Computed tomography findings in patients with pediatric blunt renal trauma in whom expectant (nonoperative) management failed.
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ABSTRACT: To determine whether the features on a computed tomography (CT) scan can predict the need for urologic intervention in a pediatric blunt renal trauma population initially treated with expectant management. A review of a prospective database of pediatric patients sustaining renal trauma from 1991 to 2003 was performed. The data reviewed included the mechanism of injury, injury grade, CT findings, operative intervention, and complications. Parametric statistical analysis was used to compare the CT findings and outcomes. A total of 72 children presented with blunt renal injury, of whom 61 met the study criteria. Of the 61 patients, 50 had grade I-III, 10 had grade IV, and 1 had grade V injuries. No children with grade I-III injuries required operative intervention. Of the 10 patients with grade IV injuries, 4 had medial contrast extravasation from the collecting system on their original CT scan, 3 of whom required intervention. Intervention initially consisted of delayed endoscopic procedures at 3, 9, and 33 days after injury. All 3 patients (100%) developed complications in their management, and 2 (66%) required open surgical intervention. The 1 patient with grade V injury underwent nephrectomy because of hemodynamic instability. Grade IV renal injuries with medial contrast extravasation are associated with urologic intervention at greater rates than those without extravasation. Delayed treatment of this finding could be associated with greater than expected complication rates and renal loss, and early/aggressive treatment should be considered. This knowledge could improve the specificity of "expectant" nonoperative management of pediatric renal injury.Urology 12/2012; 80(6):1338-44. · 2.43 Impact Factor -
Article: Urethroplasty: a geographic disparity in care.
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ABSTRACT: Urethroplasty is the gold standard for urethral strictures but its geographic prevalence throughout the United States is unknown. We analyzed where and how often urethroplasty was being performed in the United States compared to other treatment modalities for urethral stricture. De-identified case logs from the American Board of Urology were collected from certifying/recertifying urologists from 2004 to 2009. Results were categorized by ZIP codes to determine the geographic distribution. Case logs from 3,877 urologists (2,533 recertifying and 1,344 certifying) were reviewed including 1,836 urethroplasties, 13,080 urethrotomies and 19,564 urethral dilations. The proportion of urethroplasty varied widely among states (range 0% to 17%). The ratio of urethroplasty-to-urethrotomy/dilation also varied widely from state to state, but overall 1 urethroplasty was performed for every 17 urethrotomies or dilations performed. Certifying urologists were 3 times as likely to perform urethroplasty as recertifying urologists (12% vs 4%, respectively, p<0.05). Urethroplasties were performed more commonly in states with residency programs (mean 5% vs 3%). Some states reported no urethroplasties during the observation period (Vermont, North Dakota, South Dakota, Maine and West Virginia). To our knowledge this is the first report on the geographic distribution of urethroplasty for urethral stricture disease. There are large variations in the rates of urethroplasty performed throughout the United States, indicating a disparity of care, especially for those regions in which few or no urethroplasties were reported. This disparity may decrease with time as younger certifying urologists are performing 3 times as many urethroplasties as older recertifying urologists.The Journal of urology 04/2012; 187(6):2124-7. · 4.02 Impact Factor -
Chapter: Treatment of Adult-Acquired Buried Penis
08/2011; , ISBN: 978-953-307-509-9 -
Article: Buccal mucosa urethroplasty for adult urethral strictures.
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ABSTRACT: Urethral strictures are difficult to manage. Some treatment modalities for urethral strictures are fraught with high patient morbidity and stricture recurrence rates; however, an extremely useful tool in the armamentarium of the Reconstructive Urologist is buccal mucosal urethroplasty. We like buccal mucosa grafts because of its excellent short and long-term results, low post-operative complication rate, and relative ease of use. We utilize it for most our bulbar urethral stricture repairs and some pendulous urethral stricture repairs, usually in conjunction with a first-stage Johanson repair. In this report, we discuss multiple surgical techniques for repair of urethral stricture disease. Diagnosis, evaluation of candidacy, surgical techniques, post-operative care, and complications are included. The goal is to raise awareness of buccal mucosa grafting for the management urethral stricture disease.Indian Journal of Urology 07/2011; 27(3):364-70. -
Article: Trends in stricture management among male Medicare beneficiaries: underuse of urethroplasty?
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ABSTRACT: To analyze the trends in male urethral stricture management using the 1992-2001 Medicare claims data and to determine whether certain racial and ethnic groups have a disproportionate burden of urethral stricture disease. We analyzed the Medicare claims for fiscal years 1992, 1995, 1998, and 2001. The "International Classification of Disease, 9th revision," diagnosis codes were used to identify men with urethral stricture. The demographic characteristics assessed included patient age, race, and comorbidities, as measured using the Charlson index. Treatments were identified using the Physician Current Procedural Terminology Coding System, 4th edition, procedure codes and stratified into 4 treatment types: urethral dilation, direct vision internal urethrotomy, urethral stent/steroid injection, and urethroplasty. The overall rates of stricture diagnosis decreased from 10,088/100,000 population in 1992 to 6897 in 2001 (from 1.4% to 0.9%). The stricture prevalence was greatest among black and Hispanic men, although the urethroplasty rates were greatest among white men. Direct vision internal urethrotomy was the most common treatment, followed by urethral dilation, urethral stent/steroid injection, and urethroplasty. The urethroplasty rates remained stable, but quite low (0.6%-0.8%), during the study period. The overall rates of stricture diagnosis decreased from 1992 to 2001. Despite the poor overall efficacy of urethrotomy and urethral dilation relative to urethroplasty and despite the known complications of stent placement in this setting, the urethroplasty rates were the lowest of all treatments. Although we could not determine the treatment success with these data, these findings suggest an underuse of the most efficacious treatment of urethral stricture disease, urethroplasty.Urology 02/2011; 77(2):481-5. · 2.43 Impact Factor
